A 68-year-old woman comes to the urgent care clinic complaining of progressive shortness o… — USMLE Step 2 CK

A $68$ -year-old woman comes to the urgent care clinic complaining of progressive shortness of breath and a cough productive of clear, frothy sputum for the past two days. She reports needing to sleep propped up on three pillows at night. Her past medical history includes hypertension, type 2 diabetes mellitus, and a $35$ -pack-year smoking history. Her temperature is $37.1^\circ\text{C}$ ( $98.8^\circ\text{F}$ ), blood pressure is $165/95\text{ mmHg}$ , pulse is $105/\text{min}$ , and respiratory rate is $22/\text{min}$ . Oxygen saturation is $89\%$ on room air. Physical examination reveals distended jugular veins. Pulmonary auscultation shows bilateral crackles at the lung bases and scattered expiratory wheezes. Bilateral $2+$ pitting edema is noted in the lower extremities. Which of the following is the most appropriate initial therapy for this patient?

Intravenous furosemideAnswer
B
Inhaled albuterol
C
Systemic methylprednisolone
D
Intravenous piperacillin-tazobactam
E
Oral azithromycin

Answer

Intravenous furosemide

The correct answer provides the standard first-line therapy for acute decompensated heart failure. The patient's orthopnea, jugular venous distention, basilar crackles, and bilateral pitting edema are hallmark signs of volume overload. The wheezing present on exam is known as 'cardiac asthma,' which occurs secondary to peribronchial edema from elevated left heart pressures. Intravenous furosemide quickly initiates diuresis, reducing preload and alleviating pulmonary congestion.

Step-by-Step Solution

Analyze the patient's vital signs and physical examination findings.

The patient is hypoxic and tachypneic. Exam shows jugular venous distention, basilar crackles, wheezing, and lower extremity edema.

Identifying the clinical signs of volume overload is essential for establishing the correct diagnosis.

Differentiate between primarily pulmonary and primarily cardiac causes of dyspnea.

The combination of orthopnea, elevated venous pressure (JVD), and peripheral edema confirms acute decompensated heart failure. The wheezing represents 'cardiac asthma' caused by airway edema, rather than a primary COPD exacerbation.

Patients with a smoking history can have overlapping presentations, but the right-sided heart failure signs clearly point to a cardiac etiology.

Select the most appropriate initial management for the confirmed diagnosis.

Intravenous loop diuretics (e.g., furosemide) are indicated to quickly relieve pulmonary congestion and volume overload.

Diuresis is the mainstay of therapy for acute decompensated heart failure.

Key Concept

Patients with acute decompensated heart failure can present with wheezing ('cardiac asthma') due to peribronchial edema. The presence of fluid overload signs (JVD, crackles, orthopnea, peripheral edema) distinguishes this from a COPD exacerbation and dictates initial treatment with loop diuretics.

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